Why VA Health Care Is Different

Dr. Shulkin is under secretary for health at the U.S. Department of Veterans Affairs in Washington, DC.

Author disclosuresThe author reports no actual or potential conflicts of interest with regard to this article.

DisclaimerThe opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

As someone who has spent considerable time in the private sector, I can report that delivery of such services is the exception, not the rule, especially given the current system of health care reimbursement. The benefit of a holistic view is underscored by numerous outcome studies showing that the VA performs as well as, if not better than, the private sector. For example, screening and prevention outcomes at the VA have been consistently better than those at community care sites.5

Studies also suggest that standard care measures, such as control of blood pressure and hemoglobin A1c levels, are often better in VA patients compared with non-VA patients. Studies of risk-adjusted mortality rates generally found improved outcomes for VA care or little difference between VA and non-VA care.6-9 Moreover, a recent independent assessment of the VA reported that the VA performed as well as, and in some cases better than, the private sector on a number of key indicators.10

In my first year as the VA under secretary for health, I have come to appreciate these strengths even more and to sharpen my understanding of what makes VA care different from private sector care. Five distinctions are clear:

1. Veteran Patients Are Inherently Different

The VA manages a patient mix that is distinct from what civilian community providers typically treat. The majority of veterans who utilize VA health care are collectively sicker and poorer and have fewer support services than age-matched non-veteran patients.10,11 When compared with the general population, veterans are more likely to have as many as 3 additional comorbid physical conditions as well as a possible mental health diagnosis.

Similarly, the VA also cares for a higher percentage of minorities who, as a group, too often encounter barriers to care in community settings. Given these disproportionately higher numbers of patients facing access issues, the VA has done better than the private sector in reducing barriers to care for many health measures.12 For many veterans, the VA has become a lifeline of health care support and service.

2. Reimbursement and Incentives

The veteran patient population typically requires more time during a typical doctor visit than private sector physicians generally can provide. Ever-changing reimbursement schedules have forced many private sector PCPs to shorten patient visits in order to survive economically. Because VA physicians are salaried, they don’t face the same constraints on time spent with patients. Further, there is less of a mismatch between financial performance and clinical performance and, therefore, less likelihood of inappropriate tests and services.

3. VA Employees’ Sense of Mission

Almost 95% of VA staff believe the work they do is important.13 In annual employee surveys, the VA sees a high commitment to service from its employees. Additionally, 40% of VA staff are veterans, who can relate to veteran patients in ways nonveterans cannot. As under secretary for health, it has been a remarkable experience seeing this sense of mission translated into everyday care and observing the very personal connection between VA employees and patients.

This sense of mission, embedded throughout the organization, has a far-reaching impact that includes the relationships formed with veterans. In stark contrast to the private sector, where patients may receive care from multiple sources and switch providers and insurance companies with increasing frequency, veterans tend to forge lifelong relationships with the VA. In turn, this stable and consistent relationship strengthens doctor-patient communications and provides a solid foundation for shared decision making. These long-term relationships also may improve the continuity of care and the ability to track long-term outcomes.

As someone whose residency included training at VA, I’ve long appreciated the VA’s ability to advance health care, incorporate new learning, and promote best practices. These capabilities are fortified by its 70-year partnership with academic affiliates. Through academic partnerships, the VA trains tens of thousands of health care professionals yearly and conducts cutting-edge research on all the service-connected issues described above, as well as chronic illness, disparities in care, and emerging areas such as personalized medicine.

The VA Research and Development Program is the nation’s only intramural research program entirely dedicated to the health of veterans. Further, more than 60% of VA researchers are clinicians, which means their studies are framed by daily interaction with patients, and their study findings are put into practice more quickly.

5. VA Investment in Large-Scale Capabilities

As the largest integrated health care system in the U.S., the VA can invest in capabilities that are difficult for smaller systems to undertake. For example, the VA electronic medical record platform has enabled the organization to capture veteran health data systemwide for more than 2 decades, longer than almost any other health care enterprise in the country. Additionally, the ability of the VA to house and analyze “big data” is more advanced than that of most other health care systems, in part because of its considerably larger scale. This capability supports the holistic approach to care noted above and makes it possible to consider the numerous social and economic determinants of health and to track outcomes over time. This capability also supports the VA Million Veteran Program (MVP), a research effort that is building a genomic database of 1 million users of VA health care. Through the MVP, researchers will be able to use genomic and clinical data to develop personalized therapies for veterans and address some of America’s most significant research questions.14